Common Justifications for Denial of Disability Benefits

In Florida, as is the case in other states, disability benefits may be denied for a number of different reasons. Insurers often act wrongfully when denying benefits, however. If you believe that you have legitimate reason to challenge the denial of your benefits, you may appeal the denial and — having exhausted the administrative process — you may even bring a lawsuit against your insurer for wrongful denial.

On what basis do insurers justify the denial of disability benefits? Consider the following non-exhaustive list.

Disability Does Not Satisfy Plan Requirements

The definition of a “disability” that qualifies for benefits can vary significantly depending on the policy. Under some policies, specific illnesses, injuries, and conditions are outlined, with full/partial exclusions listed (for example, subjective conditions are often limited to temporary benefits).

Most policies apply an occupational standard: either own occupation or any occupation. If your disability benefits plan is an own occupation plan, then you will be considered disabled if your condition renders you incapable of working in your current occupation. If your disability benefits plan is an any occupation plan, then you will be considered disabled if your condition renders you incapable of working in any reasonable alternative occupation — the condition must therefore be severe enough that it prevents you from seeking a different career path.

Medical Record Evidence is Lacking

Your insurer may deny disability benefits if certain aspects of your medical record relating to the disability at-issue are missing or inadequate. For example, if you are attempting to claiming disability benefits but you have not made regular visits to a qualified physician to treat your condition, then the insurer will be more likely to deny benefits. Similarly, if your treating physician does not agree that your condition is sufficiently disabling to provide an opinion in your favor, then the insurer is much more likely to deny benefits.

Alcohol and Drug Abuse

Benefits may be denied if your disability is substantially caused by alcohol and/or drug abuse. If the cessation of such abuse would result in the resolution of the disability at-issue, then you are unlikely to be granted benefits. If the disability is de-linked from alcohol and/or drug abuse, then you may still be entitled to benefits, however.

Malingering

In many cases in which disability benefits are denied, the insurer asserts that the claimant is exaggerating the effect of their condition so as to secure benefits. The insurer may even conduct surveillance of the claimant to try and “catch” them out doing something that they should not be otherwise capable of if they were truly disabled. For example, suppose that you are applying for disability benefits on the basis that you have suffered a serious back injury which is preventing you from working in construction. If the insurer hires an investigator who catches you engaging in heavy physical activity that contradicts your asserted disability, then the insurer is likely to deny benefits.

Concealment of Facts

You must reveal all relevant facts on your application for disability benefits. This includes material medical record evidence, the names of treating physicians, your symptoms, your ability or inability to work, etc. If the insurer believes that you have concealed or otherwise misrepresented facts on your application, then they are likely to deny benefits on that basis.

If your insurer has denied your disability benefits claim, you may be able to challenge the decision of your insurer and potentially bring an action against them from wrongful denial of such benefits.

Ver Ploeg & Lumpkin is a Florida insurance litigation firm with a long track record of success in handling complex insurance disputes. For over two decades, our firm has helped policyholders challenge the wrongful conduct of the insurer (i.e., unreasonable denial of a valid claim, delayed payment, etc.) and obtain the benefits they are rightfully entitled to. We pride ourselves on our commitment to personalized legal advocacy, thorough preparation, and relentless advocacy on the policyholder’s behalf.

Call 305-577-3996 to get connected to one of our experienced Miami disability insurance lawyers today.